Provider Demographics
NPI:1578686549
Name:BRANDT, KATHY JANE (LRD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JANE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:JANE
Other - Last Name:LYBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 15TH ST SW
Mailing Address - Street 2:
Mailing Address - City:RUGBY
Mailing Address - State:ND
Mailing Address - Zip Code:58368-2423
Mailing Address - Country:US
Mailing Address - Phone:701-776-2948
Mailing Address - Fax:
Practice Address - Street 1:800 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:RUGBY
Practice Address - State:ND
Practice Address - Zip Code:58368-2118
Practice Address - Country:US
Practice Address - Phone:701-776-5261
Practice Address - Fax:701-776-5448
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17665OtherBLUE CROSS BLUE SHIELD
ND17665Medicare ID - Type Unspecified